Objectives
Observational data to support delaying elective pediatric thoracic surgery during peak respiratory viral illness season is lacking. This study evaluated whether lung surgery during peak ...viral season is associated with differences in postoperative outcomes and resource utilization.
Methods
A retrospective observational cohort study was performed using the Pediatric Health Information System (PHIS). Patients with a congenital lung malformation (CLM) who underwent elective lung resection between 1 January 2016 and 29 February 2020 were included. Respiratory syncytial virus (RSV) incidence was used as a proxy for respiratory viral illness circulation. Monthly hospital‐specific RSV incidence was calculated from PHIS data, and peak RSV season was defined by Centers for Disease Control data. Multivariable regression models were built to identify predictors of postoperative mechanical ventilation, which was the main outcome measure, as well as secondary outcomes including 30‐day readmission after lung resection, postoperative length of stay (LOS) and hospital billing charges.
Results
Of 1542 CLM patients identified, 344 (22.3%) underwent lung resection during peak RSV season. 38% fewer operations were performed per month during peak RSV season than during off‐peak months (p < .001). Children who underwent surgery during peak RSV season did not differ from the off‐peak group in terms of age at operation, race, or comorbid conditions (i.e., congenital heart disease, newborn respiratory distress, and preoperative pneumonia). There was no association between hospital‐specific RSV incidence at the time of surgery and postoperative mechanical ventilation, postoperative LOS, 30‐day readmission rate or hospital billing charges.
Discussion
Performing elective lung surgery in children with CLMs during peak viral season is not associated with adverse surgical outcomes or increased utilization of healthcare resources.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Minimally invasive surgery (MIS) has improved surgical access to the foregut. While the benefits of MIS versus open surgery are well accepted, the relative benefits of laparoscopic versus robotic ...approaches continue to be debated. Procedure-specific comparisons are difficult to obtain for Heller myotomy, due to the relative rarity of the procedure in most practices. A retrospective review of prospectively collected perioperative data of a single surgical practice from 2001 to 2019 was conducted for the rate of perforation during Heller myotomy laparoscopically compared to robotically. From 2001 through February 2012, a laparoscopic approach was employed and from October 2008 to 2019, a robotic approach was employed. All perforations were recorded, as well as secondary outcomes of perforation location (gastric or esophageal), postoperative imaging for evidence of leak, length of stay, and complications. Chi-square and simple
t
test were employed for data analysis. During the 11 years of laparoscopic Heller myotomy, 14 cases resulted in 7 instances of perforation (50%). During the 11 years of robotic Heller myotomy, 45 cases resulted in 11 instances of perforation (24%) (
p
value = 0.06). All perforations in both groups were tiny, recognized, and repaired immediately. The length of stay (LOS) was longer in the laparoscopic perforation group (3.4 days) compared to the laparoscopic non-perforation group (1.2 days) (
p
value = 0.06). LOS for robotic was not significantly longer in the perforation group (2.8 days) compared to the robotic non-perforation group (1.5 days) (
p
value = 0.18). First time Heller myotomies showed a higher rate of perforation with laparoscopic (50%) vs robotic (14%) (
p
value = 0.009) approach. In subgroup analysis of revisional procedures, all ten were performed robotically (
p
value < 0.001) with a 60% perforation rate (
p
value = 0.001) and one associated, radiographically confirmed leak. Primary laparoscopic Heller myotomy related to more than four times the frequency of perforation than did primary robotic myotomy. We propose that the robotic platform provided the surgeon with superior ability to avoid perforation. Interestingly, the robotic group in this study dealt with more complex redo cases. In fact, reoperation in the area of the hiatus was a separate risk factor for perforation during robotic Heller myotomy. We recommend further prospective trials be done to better evaluate the benefits of robotic platform in regard to revisional foregut surgery.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
The value of chest computed tomography (CT) in pediatric primary spontaneous pneumothorax (PSP) remains controversial. This study sought to evaluate the utility of CT scans in a contemporary cohort ...of children with PSP.
An institutional review board approval was obtained for a retrospective review of all children (aged ≤18 y) who underwent video-assisted thoracoscopic surgery (VATS) for PSP between 2009 and 2019 at a university-affiliated pediatric hospital. Preoperative CT scans were evaluated for diagnostic accuracy of the CT of bleb disease.
Thirty nine patients underwent VATS procedures for PSP, 34 (87%) of the patients were noted to have blebs. Twenty eight (72%) patients received preoperative CT scans with a 5.5:1 male to female ratio. On CT, 17 (61%) were diagnosed with blebs and all had blebs intraoperatively. CT did not identify disease in 11 patients, but seven had blebs intraoperatively. The positive and negative predictive values of preoperative CT for detecting ipsilateral bleb disease were 100% and 36%, respectively, with a sensitivity of 71%. Eleven patients had a contralateral disease on CT (39%). Five received elective contralateral VATS and three developed spontaneous PSP, with intraoperative blebs in all eight patients. Three never developed contralateral PSP. Six (21%) patients with no contralateral disease on CT developed spontaneous PSP with intraoperative blebs.
The decision to operate for PSP should be made based on clinical findings rather than on the presence or absence of blebs identified by CT.
•Primary spontaneous pneumothorax (PSP) is thought to be related to ruptured blebs and some have used evidence of blebs on imaging as an indication for surgical resection.•Computed tomography (CT) is only 71% sensitive and 36% negative predictive value for bleb disease.•Blebs on CT do not correlate with ipsilateral or contralateral recurrence rates.•CT utility for PSP is debated with low yield and increased risk of radiation and cost.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
To determine whether hospital- and surgeon-level operative volumes are associated with differences in postoperative outcomes among infants undergoing elective lung surgery for a congenital lung ...malformation (CLM).
Infant lung surgery is a relatively uncommon procedure performed by pediatric surgeons nationwide. The relationship between surgical volume and postoperative outcomes remains unknown.
A retrospective cohort study of asymptomatic infants who underwent elective lung resection of a CLM was conducted using the Pediatric Health Information System database (2016-2020). Multivariable linear and poisson regressions were performed based on annual lung resection tertiles.
There were 1420 infants managed by 48 hospitals and 309 primary surgeons. Institutions that performed seven or fewer CLM resections per year (56%) were associated with significantly higher postoperative complication rates compared to medium- and high-volume hospitals (low: 134 34%, medium: 110 21%, high: 144 29%; P<0.001). Surgeons who performed one or fewer CLM resections per year (82%) were associated with significantly higher complication rates compared to medium- and high-volume surgeons (low: 171 31%, medium: 75 26%, high: 119 24%; P=0.02). Multivariable analyses confirmed that low-volume hospitals were associated with higher complications (OR 1.81, CI 1.38-2.37; P<0.001), and low-volume surgeons had an increased risk of complications (overall: OR 1.37, CI 1.01-1.84; P=0.04).
In this cohort study of infants undergoing elective lung resection for a CLM, lower volume providers were associated with higher postoperative patient morbidity. These findings represent an opportunity to inform quality improvement initiatives on pediatric lung resection and the debate on surgical subspecialization for this unique patient population.
To compare disease severity and mortality differences between female and male patients with congenital diaphragmatic hernia (CDH).
We queried the CDH Study Group (CDHSG) database for CDH neonates ...managed between 2007 and 2018. Female and males were compared in statistical analyses using t tests, χ² tests, and Cox regression, as appropriate (P ≤ .05).
There were 7288 CDH patients, of which 3048 (41.8%) were female. Females weighed less on average at birth than males (2.84 kg vs 2.97 kg, P < .001) despite comparable gestational age. Females had similar rates of extracorporeal life support (ECLS) utilization (27.8% vs 27.3%, P = .65). Although both cohorts had equivalent defect size and rates of patch repair, female patients had increased rates of intrathoracic liver herniation (49.2% vs 45.9%, P = .01) and pulmonary hypertension (PH) (86.6% vs 81.1%, P < .001). Females had lower survival rates at 30-days (77.3% vs 80.1%, P = .003) and overall lower survival to discharge (70.2% vs 74.2%, P < .001). Subgroup analysis revealed that increased mortality was significant among those who underwent repair but were never supported on ECLS (P = .005). On Cox regression analysis, female sex was independently associated with mortality (adjusted hazard ratio 1.32, P = .02).
After controlling for the established prenatal and postnatal predictors of mortality, female sex remains independently associated with a higher risk of mortality in CDH. Further study into the underlying causes for sex-specific disparities in CDH outcomes is warranted.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Laparoscopic repair of duodenal atresia in neonates has gained popularity among some pediatric surgeons. Single-center studies suggest comparable short-term outcomes to open surgery. The purpose of ...this study was to utilize a large, multi-institutional pediatric dataset to examine 30-day post-operative outcomes by operative approach for newborns who underwent duodenal atresia repairs.
We identified neonates aged ≤1 wk in the 2016-2018 National Surgical Quality Improvement Program-Pediatric -database that underwent a laparoscopic or open repair for duodenal atresia. Preoperative characteristics were compared between operative approaches. Postoperative complications, operative time, postoperative length of stay (LOS), and supplemental nutrition at discharge were assessed using multivariate regressions.
There were 267 neonates who met inclusion criteria. There were 233 (87%) infants who underwent open repairs and 34 (13%) who underwent laparoscopic repairs. Ten (29%) children who had laparoscopy were converted to open. After adjusting for confounding, laparoscopy was associated with an increase in operative time by 65 min (95% confidence interval 45-87 min, P < 0.001) but a five-day shorter LOS (95% confidence interval −9 to −2, P = 0.006) when compared to laparotomy. There were no significant differences in postoperative complications or supplemental nutrition at discharge.
Our findings suggest that laparoscopic repairs of duodenal atresia are associated with shorter postoperative LOS but longer operative times when compared to open repairs. Although the conversion rate to laparotomy remained relatively high, the laparoscopic approach was associated with comparable 30-day postoperative outcomes.
•Laparoscopic duodenal atresia repair was uncommon with high conversion rates.•Laparoscopy had comparable postoperative complications to open procedures.•Laparoscopy was associated with longer operative times but reduced lengths of stay.•Laparoscopy had comparable rates of nutrition supplementation at discharge.•Overall results support continued use of laparoscopy for duodenal atresia repairs.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Neonatal resection is the mainstay treatment of children presenting with symptomatic congenital lung malformation (CLM) at birth. The objective of this study was to evaluate risk factors for ...increased morbidity and mortality after neonatal CLM resection using a large multicenter database.
Retrospective review of the Pediatric Health Information System database was performed. Children with a symptomatic CLM managed by lung resection before 30 days of age were included (2016 to 2021). Primary outcomes measures were postoperative respiratory complication and any complication, including death.
Of 1,791 CLM patients identified, 256 (14%) underwent neonatal resection for symptomatic disease. Pathology included 123 (48%) congenital pulmonary airway malformation, 24 (10%) bronchopulmonary sequestration, 5 (2%) congenital lobar emphysema, 16 (6%) hybrid, and 88 (34%) unclassified lesion. Preoperative mechanical ventilation and extracorporeal membrane oxygenation (ECMO) were employed in 149 (58.2%) and 17 (6.7%) of cases, respectively. The median age at resection was 6.5 days (interquartile range 2 to 23). Postoperatively, 25 (10%) required mechanical ventilation for 48 hours or more, 3 (1%) continued ECMO, and 3 (1%) required ECMO rescue. The overall respiratory complication rate was 34% (87), rate of any complication was 51% (130), median postoperative length of stay was 20 days (interquartile range 9 to 52), and mortality rate was 14.5% (37). Birthweight was inversely correlated with complication risk (incidence rate ratio 0.55, 95% CI 0.36 to 0.83, p = 0.006). Cardiac structural anomaly was associated with a 21-day longer postoperative length of stay (95% CI 6 to 35, p = 0.006) and 2.2 times increased risk of any complication (95% CI 1.18 to 4.02, p = 0.014).
In this large multicenter study, ECMO use and mortality are relatively uncommon among neonates undergoing lung resection for a symptomatic CLM. However, postoperative morbidity remains high, particularly in those with cardiac structural disease.
•Primary spontaneous pneumothorax (PSP) is rare with an incidence of 3.4 per 100,000 children.•There is no consensus on pediatric PSP management guidelines.•Video-assisted thoracoscopic surgery ...(VATS) after chest tube decompression (CTD) was associated with a longer LOS and chest tube days.•Air leak and increase in pneumothorax size at 24 h after CTD were related to progression to VATS.•Air leak and increase in pneumothorax size were combined associated with a 6-fold increased risk of recurrence in a two-year period.
The optimal timing of operative management in children with primary spontaneous pneumothorax (PSP) remains controversial. This study sought to determine early risk factors for failure of chest tube nonoperative management during the initial hospitalization in adolescents with PSP.
A retrospective review was conducted for children (aged ≤18 years) admitted to a single tertiary care referral center for their first presentation of a PSP managed with at least 48 h of chest tube decompression (CTD) alone. Patient outcomes and early risk factors for operative management were analyzed by multivariate regression.
Of the 39 patients who met inclusion criteria, 15 (38.5%) patients failed nonoperative treatment while 24 (61.5%) patients were managed with CTD therapy alone. Progression to thoracoscopic surgery was associated with longer CTD of 8 vs 3 days and hospital length of stay of 9 vs 4 days when compared to nonoperative management (p < 0.001, both). Air leak and increase in pneumothorax size at 24 h after CTD were independently associated with progression to surgery (p = 0.007, p = 0.002). Combined, these risk factors were associated with a significant increase in recurrence (OR 6.00, 95% CI 1.11–41.11, p = 0.048). There were no significant differences between PSP management strategies regarding cumulative radiation exposure or 2 year recurrence.
Air leak or increasing pneumothorax size within 24 h of CTD are highly correlated with failed nonoperative management during the initial hospitalization in pediatric patients with PSP. This data may be useful in the development of pediatric-specific treatment algorithms to optimally manage these patients.
Treatment study, Level III
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
This study aimed to evaluate the contemporary surgical management of long-gap esophageal atresia, a rare and challenging problem managed by pediatric general surgeons.
A retrospective review of the ...Pediatric Health Information System database for infants who underwent neonatal gastrostomy, followed by surgical reconstruction for long-gap esophageal atresia (2014–2021). Patients with birthweight less than 1.5 kg and those who received neonatal cardiac surgery were excluded. Outcomes were analyzed, including the need for further procedures, length of stay, and mortality.
Of 1,346 infants who underwent repair across 47 major children’s hospitals, 100 (7%) met the inclusion criteria for long-gap esophageal atresia. Cardiac anomalies were identified in 43% of patients. The median age at repair was 87 days (interquartile range, 62–133). Ten percent of patients had a planned or unplanned reoperation ≤30 days after index surgery, and 4% underwent reoperation at >30 days. The median time to reoperation was 9 days (interquartile range, 7–60). Mortality during index admission was 5%, and the median hospital length of stay was 143 days (interquartile range, 101–192). Length of stay was significantly longer in patients with cardiac anomalies (cardiac: 179 days, non-cardiac: 125 days; P < .001), and 52% of patients required at least 1 postoperative dilation. The median time to the first dilation was 70 days (interquartile range, 42–173).
This large multicenter study highlights the challenges of infants with long-gap esophageal atresia but suggests a high rate of successful delayed primary reconstruction. Hospitalizations are prolonged, and anastomotic stricture rates remain high. These data are useful for pediatric surgeons in counseling families on surgical repair strategy, timing, and postoperative outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The purpose of this study was to assess diagnostic accuracy and neonatal outcomes in fetuses with a suspected proximal gastrointestinal obstruction (GIO).
After IRB approval, a retrospective chart ...review was conducted on prenatally suspected and/or postnatally confirmed cases of proximal GIO at a tertiary care facility (2012–2022). Maternal-fetal records were queried for presence of a double bubble ± polyhydramnios, and neonatal outcomes were assessed to calculate the diagnostic accuracy of fetal sonography.
Among 56 confirmed cases, the median birthweight and gestational age at birth were 2550 g interquartile range (IQR) 2028–3012 and 37 weeks (IQR 34–38), respectively. There was one (2%) false-positive and three (6%) false-negatives by ultrasound. Double bubble had a sensitivity, specificity, positive predictive value, and negative predictive value for proximal GIO of 85%, 98%, 98%, and 83%, respectively. Pathologies included 49 (88%) with duodenal obstruction/annular pancreas, three (5%) with malrotation, and three (5%) with jejunal atresia. The median postoperative length of stay was 27 days (IQR 19–42). Cardiac anomalies were associated with significantly higher complications (45% vs 17%, p = 0.030).
In this contemporary series, fetal sonography has high diagnostic accuracy for detecting proximal gastrointestinal obstruction. These data are informative for pediatric surgeons in prenatal counseling and preoperative discussions with families.
Diagnostic Study, Level III.
•Congenital gastrointestinal obstruction (GIO) is rare with incidence of 1 in 2000 live births.•No previous reports on the diagnostic accuracy of double bubble with or without polyhydramnios have used a prenatal ultrasound database as well as a surgical registry to assess the true false negative rates.•Prenatal double bubble has high specificity and positive predictive value for GIO, which are increased when associated with polyhydramnios.•Concomitant cardiac anomalies carry an increased risk of associated complications.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
